Physiological and clinical vestibular vertigo syndromes are commonly characterized by a combination of phenomena involving perceptual, oculomotor, postural, and vegetative manifestations: vertigo, nystagmus, ataxia, and nausea. Most of the central vestibular syndromes and some of the peripheral vestibular syndromes may have a vascular etiology. Episodic vertigo and oculomotor abnormalities are common early symptoms of reduced vertebrobasilar blood flow due to the steep pressure gradient from the aorta to the terminal pontine arteries. To date, at least eight subgroups of anterior inferior cerebellar artery (AICA) infarction have been identified according to the pattern of neurootological presentations, among which the most common is the combined loss of auditory and vestibular functions. Unilateral ischemic lesions of the pontomesencephalic vestibular pathways, which run along the medial longitudinal fasciculus (MLF), predominantly cause vestibular tone imbalance in the roll plane. Unilateral thalamic infarctions may cause contralateral falling, astasia, or contralateral ocular tilt reaction (OTR).